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General Surgery Coding Alert
General Surgery Coding Alert
General Surgery Coding Alert - 2019; Volume 21, Number 12
CPT® 2020:
Prep For Musculoskeletal Code Additions
Look for drug-delivery device additions. We're rounding up all the procedure-code changes...
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Hemorrhoidectomy:
Change How You Report Internal Hemorrhoid Excision in CPT® 2020
Master code addition and revisions. CPT® 2020 delivers some changes you need to know for...
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Category III:
Don't Miss CPT® 2020 'Temporary' Code Additions
Learn tumor ablation options. Maybe you're quick to check the first four CPT® surgery se...
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MIPS:
Find Out These 2020 QPP Updates
Look for reduced specialty-specific measures. You can expect administrative relief under ...
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Reader Question:
Use Path Report or History for Dx
Question: The op note states that a patient undergoing a lumpectomy has a history of DCIS....
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Reader Question:
Check Payers for Polypectomy Bundling Rules
Question: Our surgeon performed a colonoscopy and a hot-forceps polyp excision. The op not...
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Reader Question:
Focus 'Medical Necessity' for Billing
Question: Sometimes we get denials for a procedure our surgeon performed due to lack of ...
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Reader Question:
Code Suspected Wound Infection
Question: A patient returned to our surgeon's office following a hernia procedure complain...
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You Be the Coder:
Measure Lesion and Excision For Proper Coding
Question: The surgeon “creates an elliptical excision 7 cm long surrounding a 2.0 x 1.5 ...
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General Surgery Coding Alert - 2019; Volume 21, Number 11
CPT® 2020:
Check Out Integumentary Section Changes
Grab liposuction grafting upgrade. When your surgeon performs a fat graft for conditions ...
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Evaluation and Management:
Get More from CPT® 2020 E/M Code Changes
Make sure time is on your side. You just might need to revamp your templates or other tim...
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More CPT® 2020 Changes:
Catch Time Change for Virtual QNHP Non-Face-To-Face Codes
Revisions mirror physician E/M changes. If your surgical practice engages qualified non-p...
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News You Can Use:
Prepare for MFA Protection With Medicare Provider Online Enrollment
Your MAC can be your guide. Hacking danger to your general surgery practice is not going ...
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Reader Question:
Identify Esophageal Section
Question: What is the correct diagnosis code for a malignant lesion in the “abdominal es...
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Reader Question:
Know Who Gets No-Show Bill
Question: We've established a policy for billing no-shows, and we report 99199 to payers f...
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Reader Question:
Update Documentation for Med-Student Work
Question: We have a medical student working with us at our clinic. In patient encounters, ...
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Reader Question:
Use Encryption to Protect ePHI
Question: How can we make sure encryption is part of our HIPAA compliance? Codify Subscri...
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You Be the Coder:
Capture 2-Site Marker Placement
Question: Our surgeon performed percutaneous placement of metallic pellets using stereotac...
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General Surgery Coding Alert - 2019; Volume 21, Number 10
Wound Repair:
From Closure to Cleaning – Details Drive Code Choice
Notice adhesive strip exclusion. Don't be fooled by the adage that wound repair coding si...
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E/M:
Capture Pay When Visit Time Runs Long
Follow 3 expert tips for prolonged service. Complex surgery case, records review, counsel...
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Medicare Rules:
Avoid Fraud and Abuse Charges
Unbundling is still a trap. Don't think your practice is immune from Medicare fraud and a...
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Reader Question:
Symptoms May Lead New Dx Choice
Question: The surgeon performs a diagnostic laparoscopy for a patient who has undergone pa...
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Reader Question:
Find Truth About Password Changes
Question: Our IT consultant suggests that we update passwords every 30 days, but this is m...
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Reader Question:
Check Modifier 25 Opportunity
Question: Our surgeon examined a patient in the office who had a head laceration. After th...
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You Be the Coder:
Master Endoscopic Stent Placement Coding
Question: How should I code a transendoscopic duodenal stent placement? Iowa Subscri...
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General Surgery Coding Alert - 2019; Volume 21, Number 9
Case Study:
Focus Distal Pancreatectomy Coding
Find the laparoscopic solution. Although surgical treatment of pancreatic cancer often in...
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ICD-10-CM:
Check Out Surgery-Relevant 2020 Diagnosis Codes
Start using new and revised codes Oct. 1, 2019. From history of cancer to cardiovascular ...
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Compliance:
Shun Cloned Notes in Medical Record Files
Identical claims could trigger fraud audit. Even though your electronic health (medical) ...
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Reader Question:
Manage Large Balloon Dilation Case
Question: Our surgeon performed an EGD on a patient with achalasia, and the notes sta...
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Reader Question:
Note Minor BMI Changes
Question: Our surgeons perform bariatric surgery, and BMI is one of the factors consi...
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Reader Question:
Distinguish Open and Laparoscopic Hernia Codes
Question: Would you please clarify the coding for laparoscopic versus open hernia rep...
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You Be the Coder:
Focus FNA Unit of Service
Question: How should I code FNA of left thyroid lobe nodule and FNA of thyroid isthum...
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General Surgery Coding Alert - 2019; Volume 21, Number 8
Case Study:
Skip 38531 for Laparoscopic Lymph Node with Hernia Repair
Focus on rules for ‘unlisted' procedures. Take a peek at the following case to garner t...
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Modifier Mastery:
Chart These Surgical Examples for Modifier 58 Victory
Pre-planning exemplifies staged procedures. You might lose the procedure pay you deserve ...
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Life Support:
4 Tips Create Clean ECMO Claims
Master cannula placement codes and more. If you have surgeons who are sometimes part of a...
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Reader Question:
Improve Your E/M Time Coding Accuracy
Question: I'm confused about coding E/M services by time. Do we have to document the ...
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Reader Question:
Include India Ink in Surgery
Question: During a colonoscopy, the surgeon used a snare to remove two polyps from differe...
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Reader Question:
Master Modifier 25 Tips
Question: Our surgeon saw an established patient in the office to examine a third-deg...
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You Be the Coder:
Distinguish 3 Anal Fistula Codes
Question: The op report describes the surgeon identifying an internal anal fistula op...
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General Surgery Coding Alert - 2019; Volume 21, Number 7
Needle Procedures:
Confusing FNA and PNB Could Cost You
Look for three distinguishing features in the op report. If you've ever looked at an op r...
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E/M Coding:
Make Sure Time is on Your Side for Encounter Upgrade
‘Counseling exception' is key. When your surgeon spends time counseling a patient and c...
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MIPS:
2 Keys Unlock Audit Preparedness
Secure data for six years. Participating in the Merit-Based Incentive Payment System (...
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Reader Question:
See What Dialysis Circuit Includes
Question: Please help me understand how to code the following case: Using fluoroscopic gui...
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Reader Question:
Report Relevant Post-Surgical ICD-10 Codes
Question: Following a Whipple procedure involving a total pancreatectomy that our surgeo...
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Reader Question:
Beware HIPAA Compliance Claims
Question: Our office purchased encryption software that claims to be “100-percent HIPAA ...
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You Be the Coder:
Focus Undescended Testes Case
Question: Our surgeon treated an 11-month-old with bilateral undescended testes. The op re...
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General Surgery Coding Alert - 2019; Volume 21, Number 6
Lymph Node Biopsy:
3 Expert Tips Distill Perfect 38531 Use
Don't miss bilateral pay. You've long had specific codes for open lymph node biopsies fro...
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Bundling:
Don't Miss 'Extensive' Adhesiolysis Opportunity
Make modifier 22 your friend. What can you do when your surgeon documents an abdominal or...
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Separate E/M:
Master Modifier 25 Essentials for Better Pay
Don't conflate modifiers 57 and 25. Finding both an E/M service and a surgical procedure ...
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Reader Question:
Hospital Admission Leads Consult Code Choice
Question: Our surgeon saw a non-Medicare patient in the office for a consultation, and the...
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Reader Question:
Identify Site For Line Procedure Coding
Question: I have an op report that documents a central line, arterial line, and a Swan-Gan...
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You Be the Coder:
Remember Multiple-Endoscopy Rule
Question: An endoscopic PEG tube placement procedure required some extra work, and I'm won...
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General Surgery Coding Alert - 2019; Volume 21, Number 5
Pancreas Surgery:
4 Steps Focus Whipple Code Selection
Identify approach, excisions, and resections. Surgical treatment for pancreatic cancer mi...
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ICD-10 Essentials:
Heed Excludes1 Notes For Clean Claims
Turn to the latest Coding Clinic for clarification. Maybe you groan when you turn to an I...
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OIG Report:
Make Sure You're Ready for CMS's Audit Spotlight
Code utilization could be a problem. With a recent focus on CMS's audit-recovery success,...
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Reader Question:
Limit +49568 to Specific Hernia Cases
Question: Can we separately bill mesh placement using code +49568 for hernia repairs? Ind...
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Reader Question:
Think 'A' for 'Active' Encounter
Question: Our surgeon removed sutures from a patient new to our practice who had a right-t...
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Reader Question:
Get Your CMS Info in Podcast Form
Question: I heard CMS now has a podcast to update policy information. Is that true, and if...
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Reader Question:
Focus ICD-10 For Bladder Cancer Dx
Question: Our surgeon took a bladder biopsy using a cystoscope and in the op report, descr...
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You Be the Coder:
Find Lipoma Depth for Code Selection
Question: The op note states that the surgeon removed a “5 x 5.5 cm mobile lipoma” fro...
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General Surgery Coding Alert - 2019; Volume 21, Number 4
Endoscopy:
Rouse Your Procedure and Dx Skills for This GI Case
Biopsy changes everything. When your surgeon performs multiple endoscopies on the same da...
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CPT® 2019:
Grapple With New Technology Options for E/M Services
Check perspective for 99451, 99452. Whether an E/M service involves internet, telephone, ...
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Modifier Focus:
Avoid 59 Fatigue With 3 Tips
Brush up on CMS guidance. Before you use modifier 59 (Distinct procedural service) again,...
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Reader Question:
Check Out ABN Modifier Choices
Question: We have an ABN notice for a patient's low-risk screening colonoscopy becaus...
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Reader Question:
Know Your Nose and Throat Anatomy
Question: The op note documents that the surgeon inserted a scope through the nose to exam...
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Reader Question:
Don't Miss Physician CCM Code
Question: Is there a way to report chronic care management when the physician provides the...
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You Be the Coder:
See How G0513 Can Add Up for Colonoscopy
Question: Can we use the prolonged service codes G0513 and G0514 for screening colonoscopi...
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General Surgery Coding Alert - 2019; Volume 21, Number 3
CCI Edits:
Navigate Surgery Bundles That Could Compromise Your Pay
Modifier indicator is key. Like most first-quarter Correct Coding Initiative (CCI) update...
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ICD-10 Changes:
Master Guidelines for Infection, Sepsis
Neglect sequencing rules at your peril. Each year, we rush to learn “new codes, new cod...
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HIPAA Compliance:
Protect Patients With New HHS Cybersecurity Guidance
Learn best practices for your needs. Along with electronic health records (EHR) and other...
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Reader Question:
Spotlight CF: 1 Factor for Medicare Fees
Question: What is the “conversion factor,” and how does it impact Medicare payme...
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Reader Question:
Look for Separate Appendectomy
Question: While performing an open gallbladder removal, the surgeon noted localized perito...
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Reader Question:
Prepare for LCD Changes
Question: I heard that Medicare is changing LCDs to eliminate ICD-10 codes. Does that...
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You Be the Coder:
Axillary Lymphadenectomy is Total
Question: The listed procedure on the op note is “partial mastectomy,” but the su...
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General Surgery Coding Alert - 2019; Volume 21, Number 2
Case Study:
Don't Miss Hernia Pay With This Colon Resection Case
Learn rules for separate services. When your surgeon identifies and repairs a hernia in t...
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2019 Medicare Pay:
Grasp MPFS Final Rule Impact for Your General Surgery Practice
Don't miss telehealth expansion. With payment and policy changes that could impact your g...
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2019 Final Rule:
MPFS Staggers Rollout of E/M Overhaul
Look for documentation relief this year. CMS' 2019 Medicare Physician Fee Schedule (MPFS)...
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Reader Question:
Attend to Medicare Copays and Deductibles
Question: Must we always collect Medicare patient copays and deductibles, and how do I kno...
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Reader Question:
Toenail Matrix Drives Code Choice
Question: A patient presented with a big toenail that was torn almost completely away from...
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Reader Question:
Note Details Guide Hemorrhoidectomy Coding
Question: Our surgeon excised a second-degree internal hemorrhoid group due to uncontrolla...
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Reader Question:
Distinguish Additional Lesion Excision Method
Question: The surgeon performed a skin wedge biopsy followed by a punch biopsy for a separ...
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You Be the Coder:
Use Just One Polyp Code
Question: Please help me code this op note: Surgeon resected and retrieved an 8 mm polyp i...
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General Surgery Coding Alert - 2019; Volume 21, Number 1
CPT® 2019:
Master Integumentary Biopsy Code Overhaul With 4 Tips
Technique documentation leads code choice. Almost nothing is left of the skin-biopsy sect...
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Assistant Surgeon:
Sort Out 3 Modifier Choices for Clean 'Assistant' Claims
Count on ‘80' as your work horse. However, complicated an op report might seem when you...
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Practice Management:
Duck Signature-Error Denials With These Steps
Don't lose pay over this easy compliance fix. Even a coder who's mastered CPT® and ICD-1...
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Reader Question:
Get Detailed for Intestinal Obstruction Dx
Question: I'm used to certain basic diagnoses that we face all the time, like intestinal o...
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Reader Question:
Don't Bundle E/M and X-ray
Question: An established patient reports to the surgeon reporting pain on her right side c...
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You Be the Coder:
Distinguish 36821 from 36825
Question: Surgeons in our practice sometimes create vascular access by arteriovenous fistu...
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